Discrimination Intake Questionnaire

Personal Information

Full name*

All names used in the past

Email*

Phone number*

Address*

Date of Birth*

Married?*
yesno

Race*

Sex*
malefemalenon-binary

Emergency contact (not living with you) name, relationship, and phone*

What is the best way to contact you?*

Name and address of employer at issue*

How many employees of employer at issue?*

Dates of employment with employer at issue
A. Start date B. End date*

Incident Summary

Date of incident*

Type of Discrimination:
—Please choose an option—AgeDisability Medical or Military LeaveNation of OriginReligionRetaliationSexSexual HarassmentWorkers Comp.Other

Date of First/Last Discriminatory Act
A. First date B. Last date*

Nature of dispute:
Please describe in detail the circumstances leading to and surrounding your dispute*

What was the last Discriminatory Act?

Have you filed an EEOC charge?*

Have you received a right to sue notice from the EEOC?*

Job Title*

Job Duties*

Salary or hourly employee*
salaryhourly

Last salary with employer at issue*

Did you work overtime?*
yesno

Did you work off clock?*
yesno

How many hours worked on a weekly basis*

Fringe benefits: please detail any benefits you received, including but not limited to health, vision, dental, 401k, and/or dependent coverage*

Promotional / disciplinary history:

Please describe your promotional history with the employer at issue*

Please describe your disciplinary history with the employer at issue*

If terminated / disciplined, what was the reason stated for the termination / discipline

Prior or current lawsuits: Have you been involved in any prior lawsuit or are currently involved in any lawsuits (including bankruptcy filings)?*

If so, please specify the court, case number, subject matter, and final disposition.

Who will testify for you?*
Name, title, number

Who will testify against you?*
Name, title, number

Medical/Personal History

Please list all diagnosed medical conditions that relate to your dispute

Please list all medications / prescriptions you currently take that relate to your dispute

Have you been fired from a job?*

Have you been convicted of a crime?*

Criminal: Please detail any arrests, indictments, and / or convictions*

Have you ever filed bankruptcy?*

Have you ever filed for SSI?*

Have you ever applied for short term/long term disability through employers benefit?*

Have you applied for unemployment as a result of your termination?*

Did you sign an arbitration agreement with this employer?*

What are your expectations in this lawsuit?*

Any other relevant information

How did you hear about Carter Law Group?